184 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts ��E�E�VE�
Board of Building Regulations Lind Standard
Massachusetts State Building Code, 780 MOECTIONAL SER ICE�ITY OF
ALEM
Revised Mar 2011
Building Permit Application "ro Construct, Repair, RenovzWIp,Jagn1,4shFp , Oq t
One-or Two-Family Dwelling 99 UUpp
This Section For Official Use Only
Building Permit Number: D e Applied:
1& ` do
Building Official(Print Name) Signature pate
SECTION 1:SITE INFORMATION
11 P,mNOr�Addre}s:_- I 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Number P,vccl Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use Lot Area(sq 11) Frontage(It) —
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NL(i.L c.d0,§5d) 1.7 Flood Zane Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?Checkif}es❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPt
2.1 O�Ynerl of Re rd:,, y
d1Ytr11C� JrYII /t) AJ
Name(I riot) City.Suite.ZIP
�cte-AA1 PA 01?�o 412•`W-A ite.SM
No.and Strout Telephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building"W Owner-Occupied X I Repairs(s) X I Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑
Brief De giption of Proposed Work'-: lit ,/'1,♦ av
SECTION 4: Esr1N1ATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier —x
3. Plumbing S - 2. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire _-
Su) ression) S Total All Fees: $ __
Check No. _ _Check Amount: Cash Amount:
6. Total Project Cost: $ e 0 Paid in Full 0 Outstanding Balance Due: �-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction.Supervisor License(CSL)
u.;.Y.7.iar �
License Number Expiration Date
Name of CSL Bolder
C^ I I I List CSL'fypc(see below)
af�s
No and Street Type Description
U Unrestricted(Buildings up to 35.000 cu. ft.)
City/Town,State,ZIP R Restricted 1&2 FamilyDwellin
M tvWonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address-
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject properly,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name b ow, I hereby attest under the pains and penalties of perjury that all of the information
coat.' d in t i ion is true and accurate to the best of my knowledge and understanding.
Print Owners o i tit orired Agent's Name(Iilectroaic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guaranty fund under b1.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eovloca Information on the Construction Supervisor License can be found at www.mass.eovJdns
2. When substantial work is planned,provide the information below:
Total floor area(sq. B.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count_
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalt7baths
Type of heating system Number of decks/porches
Type of cooling system _ Enclosed---Open
3. `Total Project Square Footage"nuty be substituted for`°Total Project Cost"
CITY OF SALEM, MASSAC IUSETTS
BUILDINGDEPARTNIENT
120WASHINGTONSTREET,3MFLOOR
�?nueaxf TEL. (978) 745-9595
Fivx(978) 740-9846
KIIvIBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONA4ISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date lQ fq• I - 1 /
Job Location (0 Nde, 413k e -3A (,spit _ A Q/9R
Home Owner Address (q A/s/4\ �ITed u Bit t _ jai- Q�q�
Present Mailing Address kFh-P
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
� CITY O F S'1L.E,N[, Lti L-1SSACH US ETTS
1 )`- fJLILOLNG DEPARTMFNr
120 V('ASHLNGTON S-MEET, 3w FLOOR
trati+�a;:
`! [tL (973) 7•15-9595
K1JtDERLcY OttISCOLL FAA(973) 7-W-934s
CAYO;'t
r-tosctS Sr PMvts
O EROR OF PUBLIC PROPERTy/BCILDING COSLNIISS ION ER
Comtruction Debris Disposal Afttdavit
(required focal] demolition and renovation work)
in LICCordance will, the sixdl edition of the State Building Code, 730 QjR section l l 1.5
Debris, and die provisions of IAfGL e 40, S 54;
Building Permit N I 1 work shall be is issued with the condition that the debris resulting from
l 1, S ISOA.1 disposed of in a properly licensed waste disposal facility as defined by IbfGL c
The debris will be transported by!
n r
(nJmc u hautcr)
The debris Will be disposed ot'in
(nano of I'anlity) —'
iiyna r Cp rn a Gc.uu
I I ` I
glue _--